Clinical Social Worker

Working under the supervision of the PACE Center Manager, the PACE Social Worker is independent in the application of social work knowledge and skills. He / she is responsible for providing direct social work care management services to the participants of the North East Medical Services PACE program and works collaboratively with the PACE Interdisciplinary Team (IDT) to manage long-term care needs.

ESSENTIAL JOB FUNCTIONS :

• Conducts psychosocial assessments to determine PACE Participants’ care needs, preferences, and goals.
• Participates as an active member of the IDT for Participant care planning.
• Documents accurately and thoroughly in the Participants’ electronic health record in accordance with industry and departmental standards including time requirements.
• Communicates effectively and openly with other Interdisciplinary Team members on participant status and needs.
• Maintains current and thorough written case management records, including periodic reassessments of program Participants.
• Provides supportive counseling to Participants and / or their family members, as indicated.
• May develop and lead group counseling, support groups, and / or other relevant activities.
• Refers Participants and families to appropriate community agencies or facilities, acts as a liaison with such organizations, and as an advocate for participants.
• Consults with and advises staff members regarding the social, emotional, and cultural factors associated with health and medical care, and as to the availability of social services in the community.
• Works with the IDT to manage smooth care transitions between settings (hospitals, skilled nursing facilities, home, etc.)
• Participates in program and policy development related to social work.
• Understands and demonstrates respect for Participants’ rights and utilizes established mechanisms for management of ethical issues in Participant care.
• Demonstrates active participation in Quality Improvement activities, staff training, and meetings.
• Performs home visits, as necessary.
• Works closely with the Enrollment Team to support enrollment of prospective Participants in the PACE program.
• Provides care to Participants in-person, via telehealth, and / or via telephone, as indicated.
• Utilizes Epic appropriately and efficiently and serve as content and workflow expert for resolving issues and proposing solutions in Epic.
• Performs other job duties as required by manager / supervisor.
• May provide after-hours on-call coverage to support PACE participants when the PACE Center is closed as needed for support.

QUALIFICATIONS : Required :

Preferred :

LANGUAGE :

STATUS :

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS : Competitive benefits, including free medical, dental and vision insurance for employee, spouse and / or children; and company contribution to 401(k).